Please Help with this exclusion

Treatment for obesity or services performed primarily for weight loss or control ( including gastric bypass and gastric stapling) but this shall not exclude procedures that are necessary due to a specific condition caused by another disease. Unicare claims they have never changed the plan and I know that 2 other people through my husband's company had surgery in 2003. The first was denied but based on medically necessity and once she provided other documentation. I have been denied once stating the above that I don't have the benefit. Any one have experience with this or suggestions. I am feeling desperate. Please help! Simply, Cami

Dear Cami: I have UniCare Platinum PPO for a small group. UniCare claims that they NEVER offer this coverage for ANY SMALL group plan. If your plan is in a large group, you may get them to cover. Please read my profile, or search my postings to see the long drawn out saga that I have had with UniCare. I have been fighting with them since Feb., 2005. The exclusion on my policy reads much less specific than yours, "Services primarily for weight reduction or treatment for obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment." , but they claim that it is "standard wording" and that I should "just know that they are referring to surgery". At this point, I believe that they are really playing the game of stalling until we change insurance companies. My last hope right now is the Illinois Attorney General's office mediator for my case. He has requested all of my medical records and documentation from all doctors involved, and I sent him copies of everything sent to UniCare. I do not really know at this point if I have any hope or not. I find it extremely unfair and discriminatory that UniCare can offer this coverage or not depending on the size of the company that I work for, but the Illinois Department of Insurance states that they are not breaking any laws by doing so. One thing that I did find, and it may be of benefit to you is their new medical policy, effective 4-28-05. You can see this at: http://medpolicy.unicare.com/policies%5CSURG%5Csevere_obesity.html (just copy and paste into your browser.) The other thing that I have used is the pages from this board under "Insurers" that show all of the people with UniCare that have been approved. I will let you know if I hear anything positive. Dawn So, at the moment, I can only suggest that you continue to fight them, it may go better for you than it has for me so far. It seems that many people on these boards have fought exclusions and won.